Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207Q00000X | Family Doctor | DR.0057228 | CO |
NPI | 1003203373 |
---|---|
Provider Name | Benjamin Smith |
First Address | Fort Collins, CO 80524-3257 |
Second Address | Fort Collins, CO 80524-3257 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 23/04/2015 |
Last Update Date | 20/08/2018 |